ISLAMIC KHULA CERTIFICATE APPLICATION
FORM
IMPORTANT NOTES
1. A payment of £150 is required upon submission of this form.
2. IDs are also required: Acceptable forms of IDs include: Original Marriage Certificate, UK photo
driving license, passport or official government issued photo ID. Please NOTE that it does NOT
include NUS/Student card, Birth certificate or utility bills. Please bring the original IDs at the time
of submitting the form. We will photocopy the IDs and return them to you the same day. Photocopies
of the originals will NOT be accepted.
3. Your application will be processed and the necessary enquiries will be made. Upon approval, the
applicant will be contacted to arrange Khula appointment. In cases where the application is rejected,
the applicant will be notified and informed of the reasons of rejection.
4. The Khula Application will only be processed at LIC if both parties agree on the Khula. If both
do not agree then the Khula will be rejected.
5. Both the Petitioner and the Spouse may be required to attend an interview and advice session at LIC
prior to the Khula Certificate being issued. Once Khula is decided, both the Petitioner and the Spouse
will need to be present to sign the Khula Certificate.
6. Khula certificate application is accepted during administration hours (Mon-Sun from 10am-7pm).
7. Failure to respond to the centre’s attempts of contacting you regarding your application will result in
termination of your application, loss of your application fee and copies of supporting documents
after 4 weeks of the date of submission.
8. For help with filling this form please contact 0208 690 5090 or info@lewishamislamiccentre.com
9. Please send the completed form to:
Admin Office
Lewisham Islamic Centre
363-365 Lewisham High Street
London
SE13 6NZ
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363-365 Lewisham High Street, London SE13 6NZ, United Kingdom | Tel: +44(0)208 690 5090 | Fax: +44(0)203 137 5202
Email: info@lewishamislamiccentre.com | Web: www.lewishamislamiccentre.com | Registered Charity No: 1187279
PLEASE FILL IN THE FORM USING CAPITAL/BLOCK LETTERS
Section A: PETITIONER’S DETAILS (WIFE)
1. Surname:
Forenames:
2. Address:
Town: County:
Post Code: Country:
Phone:
Email:
3. Date of birth: _ _ / _ _ / _ _ _ _Nationality: Proof of ID:_________________
4. Islamic Marriage Certificate (Nikah) Details:
Address (Place of Nikah):
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________
Date of Nikah: __ __ / __ __ / __ __ __ __
Certificate Number: _________________________________(Original Marriage Certificate required)
Section B: SPOUSE’S DETAILS (HUSBAND)
1. Surname:
Forenames:
2. Address:
Town: County:
Post Code: Country:
Phone:
Email:
3. Date of birth:_ _ / _ _ / _ _ _ _Nationality: Proof of ID:_______________
2|Page
363-365 Lewisham High Street, London SE13 6NZ, United Kingdom | Tel: +44(0)208 690 5090 | Fax: +44(0)203 137 5202
Email: info@lewishamislamiccentre.com | Web: www.lewishamislamiccentre.com | Registered Charity No: 1187279
Section B: DOWRY / MAHR AND KHULA PAYMENT AGREEMENT
Amount of Dowry / Mahr agreed_________________________________________________________
Amount of Dowry / Mahr Paid ___________________________
Amount of Dowry / Mahr Pending ________________________
Amount of Khula agreed ______________________________
Section C: WITNESSES
Note: Both Witnesses must be adult male Muslims.
1. Surname:
Forenames:
2. Address:
Town: County:
Post Code: Country:
Phone: Nationality:______________________________
Email:
(1st Witness) Sign: _________________________________ Date: ____ / ____ / _________
Section D: 2nd WITNESS:
Forenames:
2. Address:
Town: County:
Post Code: Country:
Phone: Nationality:_____________________________
Email:
(2nd Witness) Sign: _________________________________ Date: ____ / ____ / _________
Section E: Preferred day:
The following Khula appointment slots are available within the week subject to Imams’ availability; please
tick your preferred slot:
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363-365 Lewisham High Street, London SE13 6NZ, United Kingdom | Tel: +44(0)208 690 5090 | Fax: +44(0)203 137 5202
Email: info@lewishamislamiccentre.com | Web: www.lewishamislamiccentre.com | Registered Charity No: 1187279
Monday Tuesday Wednesday Friday Saturday Sunday
Checklist: Please TICK as appropriate
I have read and understood the application notes prior to filling the form.
To the best of my knowledge I have filled this form accurately.
I have affixed the required documents (such as an original Marriage Certificate, proof of ID).
I can confirm that both Witnesses will be present during the Khula appointment.
By signing this Khula application form both the Petitioner & Spouse have mutually consented to the Khula without compulsion. Lewisham Islamic
Centre reserves the right to withdraw or refuse any application if it feels necessary.
Data protection: In accordance with the General Data Protection Regulation, data collected will be used exclusively for the purpose of
producing your Khula (divorce) certificate and conducting your Khula (divorce). LIC will treat your information with utmost respect and will not
share or sell your data.
By signing below, you understand that Lewisham Islamic Centre has a legitimate interest to collect and process your personal data in order to
meet statutory requirements. Furthermore, you agree that Lewisham Islamic Centre may process your information for the purpose of which it
was intended for in accordance with our privacy notice. For further details please refer to our privacy notice on our website, under Documents.
(Petitioner) Sign: ___________________________________ Date: ____ / ____ / ________
(Spouse) Sign: ______________________________ Date: ____ / ____ / ________
Office use only:
Date form received: ____ / ____ / ________ Date form processed: ____ / ____ / ________
Form received by: _________________________ Form processed by: ______________________
IDs checked and photocopied Payment received Form Rejected Form Approved
If approved: Name of LIC Imam: _______________________________ Sign: _____________________
Date of approval: ____ / ____ / __________
Khula Certificate number: ______________________
Reason(s) if rejected: ____________________________________________________________________
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363-365 Lewisham High Street, London SE13 6NZ, United Kingdom | Tel: +44(0)208 690 5090 | Fax: +44(0)203 137 5202
Email: info@lewishamislamiccentre.com | Web: www.lewishamislamiccentre.com | Registered Charity No: 1187279
Notes: _________________________________________________________________________________
_______________________________________________________________________________________
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363-365 Lewisham High Street, London SE13 6NZ, United Kingdom | Tel: +44(0)208 690 5090 | Fax: +44(0)203 137 5202
Email: info@lewishamislamiccentre.com | Web: www.lewishamislamiccentre.com | Registered Charity No: 1187279
